Rapid Warfarin Reversal With 4-Factor Prothrombin Complex Concentrate

Samuel Z. Goldhaber, MD


November 07, 2013

4F-PCC vs Fresh Frozen Plasma

There had been a lot of concern that 4F-PCC might be associated with a rebound thrombosis and an increased rate of myocardial infarction, pulmonary embolism, or stroke. That didn't happen. In fact, 4F-PCC reversed the bleeding much more quickly than fresh frozen plasma.

Fresh frozen plasma has a lot of problems. You have to wait until it thaws, and you have to do negotiation with the blood bank. It is a big-volume load and can worsen congestive heart failure in patients who are susceptible. When a patient is bleeding and I am administering fresh frozen plasma, it seems to take forever to get reversal, and rarely does INR actually get down to 1.0 as it did in the patient I treated with 4F-PCC.

So I am very impressed with our new tool to reverse massive warfarin-related bleeding. In the Circulation paper, the patients received 4F-PCC either for intracranial hemorrhage or for gastrointestinal bleeding. It gives us an important tool. It also appears, in an "off-label sense," that 4F-PCC is the way to reverse much of the bleeding that occurs with the novel oral anticoagulants, although this will require further research.

Instead of using the old approach of vitamin K and fresh frozen plasma when you have a patient with critical bleeding due to warfarin, think about asking the blood bank to prepare 4F-PCC. Don't forget to infuse 5-10 mg of intravenous vitamin K.

This is Dr. Sam Goldhaber, signing off for the Clotblog.


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